|
SEPARATOR 5
|
Facility
|
OP
|
$4,681.25
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,404.38 |
| Max. Negotiated Rate |
$4,494.00 |
| Rate for Payer: Aetna Commercial |
$3,604.56
|
| Rate for Payer: Anthem Medicaid |
$1,609.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,651.38
|
| Rate for Payer: Cash Price |
$2,340.62
|
| Rate for Payer: Cigna Commercial |
$3,885.44
|
| Rate for Payer: First Health Commercial |
$4,447.19
|
| Rate for Payer: Humana Commercial |
$3,979.06
|
| Rate for Payer: Humana KY Medicaid |
$1,609.88
|
| Rate for Payer: Kentucky WC Medicaid |
$1,626.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,838.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,454.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,404.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,642.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,119.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,510.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,745.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,072.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,230.06
|
| Rate for Payer: PHCS Commercial |
$4,494.00
|
| Rate for Payer: United Healthcare All Payer |
$4,119.50
|
|
|
SEPARATOR 7
|
Facility
|
OP
|
$9,132.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.60 |
| Max. Negotiated Rate |
$8,766.72 |
| Rate for Payer: Aetna Commercial |
$7,031.64
|
| Rate for Payer: Anthem Medicaid |
$3,140.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.96
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cigna Commercial |
$7,579.56
|
| Rate for Payer: First Health Commercial |
$8,675.40
|
| Rate for Payer: Humana Commercial |
$7,762.20
|
| Rate for Payer: Humana KY Medicaid |
$3,140.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,172.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,488.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,739.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,203.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,036.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,944.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,301.08
|
| Rate for Payer: PHCS Commercial |
$8,766.72
|
| Rate for Payer: United Healthcare All Payer |
$8,036.16
|
|
|
SEPARATOR 7
|
Facility
|
IP
|
$9,132.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.60 |
| Max. Negotiated Rate |
$8,766.72 |
| Rate for Payer: Aetna Commercial |
$7,031.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.96
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cigna Commercial |
$7,579.56
|
| Rate for Payer: First Health Commercial |
$8,675.40
|
| Rate for Payer: Humana Commercial |
$7,762.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,488.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,739.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,036.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,944.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,301.08
|
| Rate for Payer: PHCS Commercial |
$8,766.72
|
| Rate for Payer: United Healthcare All Payer |
$8,036.16
|
|
|
SEPARATOR 7D
|
Facility
|
IP
|
$9,132.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.60 |
| Max. Negotiated Rate |
$8,766.72 |
| Rate for Payer: Aetna Commercial |
$7,031.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.96
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cigna Commercial |
$7,579.56
|
| Rate for Payer: First Health Commercial |
$8,675.40
|
| Rate for Payer: Humana Commercial |
$7,762.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,488.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,739.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,036.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,944.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,301.08
|
| Rate for Payer: PHCS Commercial |
$8,766.72
|
| Rate for Payer: United Healthcare All Payer |
$8,036.16
|
|
|
SEPARATOR 7D
|
Facility
|
OP
|
$9,132.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.60 |
| Max. Negotiated Rate |
$8,766.72 |
| Rate for Payer: Aetna Commercial |
$7,031.64
|
| Rate for Payer: Anthem Medicaid |
$3,140.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.96
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cigna Commercial |
$7,579.56
|
| Rate for Payer: First Health Commercial |
$8,675.40
|
| Rate for Payer: Humana Commercial |
$7,762.20
|
| Rate for Payer: Humana KY Medicaid |
$3,140.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,172.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,488.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,739.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,203.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,036.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,944.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,301.08
|
| Rate for Payer: PHCS Commercial |
$8,766.72
|
| Rate for Payer: United Healthcare All Payer |
$8,036.16
|
|
|
SEP D
|
Facility
|
OP
|
$9,132.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.60 |
| Max. Negotiated Rate |
$8,766.72 |
| Rate for Payer: Aetna Commercial |
$7,031.64
|
| Rate for Payer: Anthem Medicaid |
$3,140.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.96
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cigna Commercial |
$7,579.56
|
| Rate for Payer: First Health Commercial |
$8,675.40
|
| Rate for Payer: Humana Commercial |
$7,762.20
|
| Rate for Payer: Humana KY Medicaid |
$3,140.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,172.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,488.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,739.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,203.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,036.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,944.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,301.08
|
| Rate for Payer: PHCS Commercial |
$8,766.72
|
| Rate for Payer: United Healthcare All Payer |
$8,036.16
|
|
|
SEP D
|
Facility
|
IP
|
$9,132.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,739.60 |
| Max. Negotiated Rate |
$8,766.72 |
| Rate for Payer: Aetna Commercial |
$7,031.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,122.96
|
| Rate for Payer: Cash Price |
$4,566.00
|
| Rate for Payer: Cigna Commercial |
$7,579.56
|
| Rate for Payer: First Health Commercial |
$8,675.40
|
| Rate for Payer: Humana Commercial |
$7,762.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,488.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,739.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,739.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,036.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,849.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,305.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,944.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,301.08
|
| Rate for Payer: PHCS Commercial |
$8,766.72
|
| Rate for Payer: United Healthcare All Payer |
$8,036.16
|
|
|
SEPTOPLASTY
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 30520
|
| Hospital Charge Code |
76101132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.62 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$841.39
|
| Rate for Payer: Ambetter Exchange |
$619.75
|
| Rate for Payer: Anthem Medicaid |
$376.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$619.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$619.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$743.70
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$787.50
|
| Rate for Payer: Healthspan PPO |
$709.56
|
| Rate for Payer: Humana Medicaid |
$376.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$777.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$619.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$619.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.15
|
| Rate for Payer: Molina Healthcare Passport |
$376.62
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$805.67
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$619.75
|
|
|
SEPTOPLASTY
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 30520
|
| Hospital Charge Code |
76101132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$619.02 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
SEPTOPLASTY
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 30520
|
| Hospital Charge Code |
76101132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$540.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT
|
Facility
|
OP
|
$4,195.14
|
|
|
Service Code
|
CPT 30520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,996.53 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
|
|
SEPTOPLASTY(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 30520
|
| Hospital Charge Code |
761P1132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.62 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$841.39
|
| Rate for Payer: Ambetter Exchange |
$619.75
|
| Rate for Payer: Anthem Medicaid |
$376.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$619.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$619.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$743.70
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$787.50
|
| Rate for Payer: Healthspan PPO |
$709.56
|
| Rate for Payer: Humana Medicaid |
$376.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$777.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$619.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$619.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.15
|
| Rate for Payer: Molina Healthcare Passport |
$376.62
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$805.67
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$619.75
|
|
|
SEPTRA (SULFA/TMP 5/1MG/10ML)
|
Facility
|
IP
|
$119.16
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
25003442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$114.39 |
| Rate for Payer: Aetna Commercial |
$91.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.94
|
| Rate for Payer: Cash Price |
$59.58
|
| Rate for Payer: Cigna Commercial |
$98.90
|
| Rate for Payer: First Health Commercial |
$113.20
|
| Rate for Payer: Humana Commercial |
$101.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.86
|
| Rate for Payer: Ohio Health Group HMO |
$89.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.22
|
| Rate for Payer: PHCS Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Payer |
$104.86
|
|
|
SEPTRA (SULFA/TMP 5/1MG/10ML)
|
Facility
|
OP
|
$119.16
|
|
|
Service Code
|
HCPCS J2865
|
| Hospital Charge Code |
25003442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.75 |
| Max. Negotiated Rate |
$114.39 |
| Rate for Payer: Aetna Commercial |
$91.75
|
| Rate for Payer: Anthem Medicaid |
$40.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.94
|
| Rate for Payer: Cash Price |
$59.58
|
| Rate for Payer: Cigna Commercial |
$98.90
|
| Rate for Payer: First Health Commercial |
$113.20
|
| Rate for Payer: Humana Commercial |
$101.29
|
| Rate for Payer: Humana KY Medicaid |
$40.98
|
| Rate for Payer: Kentucky WC Medicaid |
$41.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.86
|
| Rate for Payer: Ohio Health Group HMO |
$89.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.22
|
| Rate for Payer: PHCS Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Payer |
$104.86
|
|
|
SEPTRA(TRIMETH/SULFAMETH) 20ML
|
Facility
|
IP
|
$9.59
|
|
|
Service Code
|
NDC 121085416
|
| Hospital Charge Code |
25001382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$9.21 |
| Rate for Payer: Aetna Commercial |
$7.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.96
|
| Rate for Payer: First Health Commercial |
$9.11
|
| Rate for Payer: Humana Commercial |
$8.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.44
|
| Rate for Payer: Ohio Health Group HMO |
$7.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.62
|
| Rate for Payer: PHCS Commercial |
$9.21
|
| Rate for Payer: United Healthcare All Payer |
$8.44
|
|
|
SEPTRA(TRIMETH/SULFAMETH) 20ML
|
Facility
|
OP
|
$9.59
|
|
|
Service Code
|
NDC 121085416
|
| Hospital Charge Code |
25001382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.88 |
| Max. Negotiated Rate |
$9.21 |
| Rate for Payer: Aetna Commercial |
$7.38
|
| Rate for Payer: Anthem Medicaid |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.96
|
| Rate for Payer: First Health Commercial |
$9.11
|
| Rate for Payer: Humana Commercial |
$8.15
|
| Rate for Payer: Humana KY Medicaid |
$3.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.44
|
| Rate for Payer: Ohio Health Group HMO |
$7.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.62
|
| Rate for Payer: PHCS Commercial |
$9.21
|
| Rate for Payer: United Healthcare All Payer |
$8.44
|
|
|
SERI SCAFFOLD 10CM*25CM
|
Facility
|
OP
|
$17,350.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,205.00 |
| Max. Negotiated Rate |
$16,656.00 |
| Rate for Payer: Aetna Commercial |
$13,359.50
|
| Rate for Payer: Anthem Medicaid |
$5,966.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,533.00
|
| Rate for Payer: Cash Price |
$8,675.00
|
| Rate for Payer: Cigna Commercial |
$14,400.50
|
| Rate for Payer: First Health Commercial |
$16,482.50
|
| Rate for Payer: Humana Commercial |
$14,747.50
|
| Rate for Payer: Humana KY Medicaid |
$5,966.66
|
| Rate for Payer: Kentucky WC Medicaid |
$6,027.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,227.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,804.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,205.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,086.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,268.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,094.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,971.50
|
| Rate for Payer: PHCS Commercial |
$16,656.00
|
| Rate for Payer: United Healthcare All Payer |
$15,268.00
|
|
|
SERI SCAFFOLD 10CM*25CM
|
Facility
|
IP
|
$17,350.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,205.00 |
| Max. Negotiated Rate |
$16,656.00 |
| Rate for Payer: Aetna Commercial |
$13,359.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,533.00
|
| Rate for Payer: Cash Price |
$8,675.00
|
| Rate for Payer: Cigna Commercial |
$14,400.50
|
| Rate for Payer: First Health Commercial |
$16,482.50
|
| Rate for Payer: Humana Commercial |
$14,747.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,227.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,804.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,205.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,268.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,012.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,094.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,971.50
|
| Rate for Payer: PHCS Commercial |
$16,656.00
|
| Rate for Payer: United Healthcare All Payer |
$15,268.00
|
|
|
SEROMYCIN 250MG CAPSULE
|
Facility
|
OP
|
$141.67
|
|
|
Service Code
|
NDC 13845120202
|
| Hospital Charge Code |
25001384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$109.09
|
| Rate for Payer: Anthem Medicaid |
$48.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.50
|
| Rate for Payer: Cash Price |
$70.83
|
| Rate for Payer: Cigna Commercial |
$117.59
|
| Rate for Payer: First Health Commercial |
$134.59
|
| Rate for Payer: Humana Commercial |
$120.42
|
| Rate for Payer: Humana KY Medicaid |
$48.72
|
| Rate for Payer: Kentucky WC Medicaid |
$49.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.67
|
| Rate for Payer: Ohio Health Group HMO |
$106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.75
|
| Rate for Payer: PHCS Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Payer |
$124.67
|
|
|
SEROMYCIN 250MG CAPSULE
|
Facility
|
IP
|
$141.67
|
|
|
Service Code
|
NDC 13845120202
|
| Hospital Charge Code |
25001384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.50 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$109.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.50
|
| Rate for Payer: Cash Price |
$70.83
|
| Rate for Payer: Cigna Commercial |
$117.59
|
| Rate for Payer: First Health Commercial |
$134.59
|
| Rate for Payer: Humana Commercial |
$120.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.67
|
| Rate for Payer: Ohio Health Group HMO |
$106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.75
|
| Rate for Payer: PHCS Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Payer |
$124.67
|
|
|
SEROQUEL 400MG EQUIV TABLET
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 68180045001
|
| Hospital Charge Code |
25003443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
SEROQUEL 400MG EQUIV TABLET
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 68180045001
|
| Hospital Charge Code |
25003443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
SEROQUEL (QUETIAP FUM)100MGTAB
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 60687034901
|
| Hospital Charge Code |
25001385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.69
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.49
|
| Rate for Payer: Humana Commercial |
$4.02
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.16
|
| Rate for Payer: Ohio Health Group HMO |
$3.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SEROQUEL (QUETIAP FUM)100MGTAB
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 60687034901
|
| Hospital Charge Code |
25001385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.69
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.49
|
| Rate for Payer: Humana Commercial |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.16
|
| Rate for Payer: Ohio Health Group HMO |
$3.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.26
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SEROQUEL (QUETIAP FUM)25MGTAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 60687032701
|
| Hospital Charge Code |
25001386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
